Chronic Constipation

About 25% of you are living with chronic constipation, resulting in many of you walking around feeling backed up, experiencing discomfort and dissatisfaction with your bowel movements or lack thereof.

The positive news is that constipation is a manageable condition, and you can achieve regular and satisfying bowel movements.

What is constipation?

Constipation is a condition where a person has trouble passing stool with ease.

Symptoms of Constipation:

• Very hard or dry lumpy stools that resemble sheep or rabbit droppings.

• Straining, if you’re groaning, moaning, pushing, and straining to get anything to pass.

• Infrequent bowel movements: The bowels open less than three times per week.

• The feeling of incomplete evacuation, despite straining, with a feeling that there is poo left in there.

• The sensation of obstruction or blockage, there feels like something is stopping the poo from moving through your bowel smoothly.

• Spending too long in the toilet, taking more than a couple of minutes to pass a poo.

• Pain in the rectum or anus.

• Using fingers or toilet paper to remove stool or support the pelvic floor manually.

• Abdominal pain or discomfort

• Bloating or distension

• Heartburn

• Nausea

Sheep droppings

What is a normal poo?

For the dog lovers out there, I believe they offer a fantastic analogy for what a regular poop experience should resemble, metaphorically speaking, of course.

1. Feel the urge.

2. Find a good spot, and do a little twirl.

3. Adopt the squatting position (don’t look at me!)

4. Empty bowels with ease, a quick kick-kick.

5. Have a little squizz; everything looks good.

6. Wait eagerly for the human to clean up the mess (hurry up!).

7. Prance off feeling much lighter and ready to pee on some things.

A normal healthy human poo should be:

• Brown in colour, ranging from light to dark brown.

• Formed in the shape of a sausage or snake, smooth and soft or like a cob of corn with cracks on the surface. (Type 3-4 on Bristol Stool Scale).

• Smoothly passed without blood or pain.

• The expected frequency of opening the bowels is three times daily to once every three days.

Bristol Stool Form Scale (for children) or adults with a sense of humour!

Who experiences constipation?

According to a 2019 study of Australian adults, 24.0% experience chronic constipation, and 39.6% experience sub-chronic constipation. While everyone with a large bowel can experience constipation, it is more common in women (geez, thanks to female sex hormones!), older individuals, and people with lower incomes.

Diagnosis of constipation

Occasional constipation can be expected due to changes in routine, travel, or diet. For instance, when travelling and encountering bathroom anxiety due to unfamiliar surroundings, insufficient water intake, and consuming different foods during your journey can contribute to this. Upon reaching your destination, as you settle in and establish a more familiar routine, bowel movements often return to normal. This type of transient constipation typically doesn’t require a visit to your doctor.

It’s good to see your GP for support to resolve your constipation and to rule out any potential more sinister causes of constipation:

• It impacts your day-to-day quality of life.

• It persists for an extended period or occurs suddenly.

• Or altered bowel movements occur after turning 50.

• Involves blood in your poo (yes, you should be looking)

• It is accompanied by weight loss without trying, even if you think the loss of weight is good.

• If there is a family history of bowel disease (cancer, coeliac disease, or inflammatory bowel disease).

Constipation Diagnostic criteria

The diagnosis of conditions like Irritable Bowel Syndrome with Constipation (IBS-C), Functional Constipation, and Opioid-Induced Constipation relies on the Rome IV Diagnostic Criteria for Disorder of Gut-Brain Interaction (DGBI).

Irritable Bowel Syndrome (IBS)

Recurrent abdominal pain on average at least 1 day/week in the last 3 months, associated with two or more of the following criteria:

1. Related to defecation

2. Associated with a change in the frequency of stool

3. Associated with a change in form (appearance) of stool

Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.

IBS with predominant constipation (IBS-C)

• More than 25% of Bristol stool types 1 or 2 bowel movements and less than 25% of Bristol stool types 6 or 7.

Functional Constipation

1. Must include two or more of the following:

   1. Straining during more than 25% of defecations

   2. Lumpy or hard stools more than 25% of defecations

   3. Sensation of incomplete evacuation of more than 25% of defecations

   4. The sensation of anorectal obstruction/blockage more than 25% of defecations

   5. Manual maneuvers to facilitate more than 25% of defecations (e.g., digital evacuation, support of the pelvic floor)

   6. Fewer than three spontaneous bowel movements per week

2. Loose stools are rarely present without the use of laxatives

3. Insufficient criteria for irritable bowel syndrome

Criteria fulfilled for the last 3 months with symptoms onset at least 6 months before diagnosis.

Opioid Induced Constipation

1. New or worsening symptoms of constipation when initiating, changing, or increasing opioid therapy must include two or more of the following:

   1. Straining during more than 25% of defecations

   2. Lumpy or hard stools more than 25% of defecations

   3. Sensation of incomplete evacuation of more than 25% of defecations

   4. The sensation of anorectal obstruction/blockage in more than 25% of defecations

   5. Manual maneuvers to facilitate more than 25% of defecations (e.g., digital evacuation, support of the pelvic floor)

   6. Fewer than three spontaneous bowel movements per week

   7. Loose stools are rarely present without the use of laxatives.

What causes or contributes to constipation?

Types of functional constipation

• Normal transit constipation, including irritable bowel syndrome with constipation (most common)

• Slow transit constipation (common in women)

• Defecatory disorders

Secondary causes of constipation:

• Organic: colorectal cancer, extra-intestinal mass

• Endocrine or metabolic: diabetes mellitus, hypothyroidism, chronic renal insufficiency

• Neurological: spinal cord injury, Parkinson’s disease, paraplegia, Hirschsprung’s disease

• Anorectal: anal fissure, anal stricture, inflammatory bowel disease

• Drugs: opiates, blood pressure medications, some antidepressants, drugs for epilepsy….a long list

• Supplements: iron, calcium

• Diet: insufficient fluid intake, unbalanced fibre intake, inadequate food intake

• Lifestyle: lack of movement, supplements, drug use

• Behavioural: withholding, routine, positioning

• Psychological: eating disorders, anxiety, depression, stressful life events

Eight strategies for managing chronic constipation

1. See your GP to ease your mind, get a referral to see a dietitian, and rule out any serious causes.

2. Stay hydrated by drinking plenty of water and fluids.

3. Consume enough fibre, balancing intake.

4. Move your body; physical activity gets your digestive system moving.

5. Overcome poo fright.

6. Practice relaxation techniques.

7. Consider using a squatty potty (even if you’re not constipated)

8. If other strategies fail, consult a gut health dietitian for individualised support and dietary advice to help to relieve constipation.

References

Barberio, B., Judge, C., Savarino, E. V., & Ford, A. C. (2021). Global prevalence of functional constipation according to the Rome criteria: a systematic review and meta-analysis. The Lancet Gastroenterology & Hepatology, 6, 8, p638-648. https://www.thelancet.com/journals/langas/article/PIIS2468-1253(21)00111-4/fulltext

Judkins, C. P., Wang, Y., Jelinic, M., Bobik, A., Vinh, A., Sobey, C. G., & Drummond, G. R. (2023). Association of constipation with increased risk of hypertension and cardiovascular events in elderly Australian patients. Scientific Reports, 13. https://www.nature.com/articles/s41598-023-38068-y

Werth, B. L., Williams, K. A., Fisher, M. J., & Pont, L. G. (2019). Defining constipation to estimate its prevalence in the community: results from a national survey. BMC Gastroenterology, 19, 75. https://link.springer.com/article/10.1186/s12876-019-0994-0

Werth, B. L., Williams, K. A., Fisher, M. J., & Pont, L. G. (2020). Chronic constipation in the Community: A National Survey of Australian Adults. Journal of Wound, Ostomy and Continence Nursing, 47, 3, p 259-264. https://journals.lww.com/jwocnonline/abstract/2020/05000/chronic_constipation_in_the_community__a_national.10.aspx?context=featuredarticles